Formulir Pendaftaran Anggota HPCI
HondaPCX Club Indonesia
DATA PRIBADI
PERSONAL PARTICULARS
Nama Lengkap
Full Name
Your answer
Jenis Kelamin
Tempat Lahir
Place of birth
Your answer
Tanggal Lahir
MM
/
DD
/
YYYY
Alamat
Address
Your answer
Telepon Selular
Mobil Phone
Your answer
Telepon Darurat
Emergency Number
Your answer
Email
Email Address
Your answer
Jenis Identitas
Type of Identity
Nomor Identitas
Identity No
Your answer
Agama
Religion
Golongan Darah
Blood type
Your answer
DATA KENDARAAN
VIHICLES INFORMATION
Nomor Polisi
License Plate
Your answer
Warna Motor
Color Of PCX
Your answer
Nomor STNK
No. Reg STNK
Your answer
Tahun Pembuatan
Year Manufacture
Your answer
No. Rangka
Chassis Number
Your answer
No. Mesin
Marchine Number
Your answer
Catatan
Pertanyaan Kritik & Saran
Your answer
Pernyataan
Required
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